AMERICAN INDIAN ELDERS’ RESILIENCE: SOURCES OF STRENGTH FOR BUILDING A HEALTHY FUTURE FOR YOUTH

Abstract

This study examined American Indian (AI) elders’ resilience to support an intervention to build resilience among AI urban youth. A literature review of peer-reviewed articles that address resilience in AI and other Indigenous elders yielded six studies that focused on intergenerational relationships, culture, and self-identity. In addition, a qualitative research project collected narratives with urban AI elders to document perceptions of resilience and resilience strategies. The combined outcomes of the literature search and research project revealed how resilience is exemplified in elders’ lives and how resilience strategies are linked to cultural teachings and values, youth activities, and education.

INTRODUCTION

American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) elders are the keepers and transmitters of knowledge that can build healthy futures for generations (Garrett et al., 2014; Ka’opua, Braun, Browne, Mokuau, & Park, 2011; Wexler, 2011). Their life stories hold rich lessons and foundational knowledge that can be key to developing positive AI/AN/NH youth cultural identity and life skills (Garrett et al., 2014; Sarche & Whitesell, 2012; Wexler, 2011). AI/AN/NH elders survived and even thrived by developing resilience strategies in response to adverse situations, including historical trauma, social and political injustice, and discriminatory practices of the U.S. government (Brave Heart & DeBruyn, 1998; Grandbois & Sanders, 2009; Masten, 1994). In this context, resilience among elders is defined as adaptation in the face of risk and adversity (Grandbois & Sanders, 2009; Masten, 1994). The knowledge and experiences of elders can inform culturally centered public health approaches that nurture and support the well-being of AI/AN/NH youth. This study combines a literature review of studies exploring AI/AN/NH elder resilience with results from a qualitative research project that documented AI urban elders’ stories of resilience. The purpose of integrating the outcomes of a literature review and primary data collection was to identify the range of protective strategies of AI/AN/NH elders to inform the design of resilience education for urban AI youth.

Existing studies have identified a current and growing disconnect between AI/AN/NH generations, prompting a movement among AI/AN/NH communities to reconnect elders with youth (Goodkind, Hess, Gorman, & Parker, 2012; Tyer, 2015; Wexler, 2011). Transmitting knowledge and life lessons intergenerationally may help youth overcome their own adversities (Wexler, 2011; Goodkind et al., 2012). Cultural engagement, social support, and strong cultural identity have been identified as important protective strategies for AI/AN/NH youth development and resilience (EchoHawk, 1997; LaFromboise, Hoyt, Oliver, & Whitbeck, 2006; Wexler, 2014; Wexler, DiFluvio, & Burke, 2009). Additional strategies contributing to AI/AN/NH resilience in general include spirituality, ceremonies, oral tradition, tribal identity, humor, elders, and family relationships (HeavyRunner & Morris, 1997). Research that investigates whether these strategies protect urban AI populations is limited.

AI/AN youth in urban settings may face even greater challenges in developing strategies to build resilience. They may have fewer opportunities to connect with AI/AN elders, as they have limited cultural and community engagement and less access to tribal resources (Stumblingbear-Riddle & Romans, 2012). Urban AI/AN youth also experience a high prevalence of risk behaviors compared to White youth in urban areas for indicators related to unintentional injury, safety, violence, and drug use (Urban Indian Health Institute [UIHI], 2009). For example, urban AI/AN youth reported three times higher rates of attempted suicide and five times rates of injury resulting from a suicide attempt than urban White youth (UIHI, 2009). Reports of being hurt by a boy/girlfriend and carrying a gun within the past 30 days were twice as high, and reports of not attending school because of feeling unsafe were three times higher among urban AI/AN youth (UIHI, 2009). Compared to White youth, initiation of marijuana use before age 13 and use of it on school property within the past 30 days were two-fold higher for AI/AN youth. These disparities in health risk behaviors call for interventions aimed at improving AI/AN youth resilience.

METHODS

Review of Literature

A review of the literature was conducted following procedures from the Cochrane Collaboration (Higgins & Green, 2011) using three databases: Medline/PubMed, Web of Science, and Education Resource Information Center. The review used the following inclusion criteria: (1) peer-reviewed articles available in English; (2) available online and published from January 1, 1980 to December 31, 2013; (3) identified U.S.-based Indigenous elders as the primary target populations by using the terms AI, Native American, AN, and/or NH, and elders; (4) described non clinical-based studies; and (5) made specific reference to one or more of the following search terms: resilience (or sociocultural characteristics linked to resilience), culture, intergenerational, and community. The research team identified these search terms based on the main themes identified from the Urban AI Elders’ Research Project, described below.

Data for the review were abstracted using a standard format. The results were organized by author, publication year, participant information, and study design, with a summary of results and discussion.

Urban AI Elders’ Research Project

Team members from a research partnership between the Tucson Indian Center (TIC) and the University of Arizona’s Center for American Indian Resilience (CAIR) interviewed 13 AI urban elders to document narratives of resilience. The inclusion criteria were self-identification as AI, ages 55 years and older, residence in Tucson, AZ, and willingness to provide written consent for recording personal life stories for research purposes. The university-based research team, made up of three Native and two non-Native investigators, initially developed an open-ended, semi-structured 16-question interview guide.

Fifteen self-selected AI elders participated in a consensus panel, in which they facilitated a group decision process and modified, then finalized, the interview guide (for full details on how a consensus panel is conducted, see Coreil, 1995). The format yielded a 25-question interview guide designed to document elders’ experiences and perceptions of historical trauma and resilience, as well as recommendations for youth navigating today’s world. The modified interview guide was used in individual, face-to-face, video- and/or audio-recorded interviews with 13 AI/AN elders, each lasting 1–3 hours.

The study was designed to learn about resilience and resilience strategies from the elders’ points of view. The research team thus did not use a resilience scale to determine whether the elders’ in the study were resilient. Instead, the research team listened to their stories and qualitatively identified strategies elders had used to overcome adversities in their lifetime.

All interviews were transcribed verbatim. Six research team members each read two to four interviews to identify themes and to develop a codebook containing both inductive and deductive thematic codes and associated pattern codes (Patton, 2014). A thematic analysis was conducted using NVivo, a qualitative data analysis program. Two researchers applied the codes to all interviews independently and used intercoder-reliability scores, a function of NVivo, to guide consensus-building discussions. The research team and elders at the TIC offered feedback for the resulting thematic analysis. The data coded for the theme “youth resilience” were compiled and analyzed in a search for themes and patterns from the elders’ narratives.

RESULTS

Literature Review

The initial search yielded a total of 138 potential articles. A total of 92 abstracts were reviewed initially; 46 abstracts did not actually address resilience strategies and 58 did not discuss resilience in the target populations. The process yielded seven articles that described elder resilience in relation to intergenerational and interpersonal relationships and/or cultural strengths. One of the seven articles was removed because it did not specifically discuss resilience factors as an outcome.

Of the six articles included in the review (Table 1), four (Browne, Mokuau, & Braun, 2009; Grandbois & Sanders, 2009, 2012; Schure, Odden, & Goins, 2013) directly investigated or measured resilience through narration, historical events, or standardized scales. The other two articles (Wexler, 2011, 2014) described the same study, which investigated intergenerational dialogue as a method to bridge the gap between AN elders and youth and to support cultural transmission to build resilience among youth.

Table 1. Articles Addressing American Indian, Alaska Native, and Native Hawaiian Elders’ Resilience Strategies.

Authors	Participants	Design	Outcomes and Application
Grandbois & Sanders, 2009	8 AI elders, ages 57–83 years	Storytelling used to explore AI elder resilience. Outcomes of thematic analysis of interviews cross-checked with respondents.	Themes identified: strategies of resilience are grounded in AI identity and connection felt with creation. Recommendations for mental health services are: offer culture-based online materials for elders, establish a “cultural consultant” network to answer questions, collaborate with AI communities to develop mental health services, train more AI mental health professionals, and include resilience strategies into mental health services.
Grandbois & Sanders, 2012	8 AI elders, ages 57–83 years	Storytelling used to examine AI elders’ experiences with stereotypes and resilience.	Themes identified: culture and strong self-identity supported resilience relative to stereotyping. Recommendation for mental and physical health services to reinforce culture in the care of AI elders.
Browne, Mokuau, & Braun, 2009	Not applicable	Developed a model to investigate social and health disparities among NH elders by using a literature review of life course and resilience theories to develop a timeline with cultural and historical markers within the lives of NH elders. The timeline is linked to social/health delivery strategies.	Key historical events identified pre-1915 to post- 1975. Loss of culture has impacted the health of the older cohort of elders, but cultural renaissance may be beneficial in restoring health. Recommendation for social work practice to include culturally appropriate services that consider historical and cultural markers as well as resilience strategies within the lives of NH elders.
Schure, Odden, & Goins, 2013	185 AI elders, ages 55 years and older	Assessed association of resilience with mental health (using depression and mental health scales) and physical health (using physical health and chronic pain scales).	Demonstrated attenuated associations between resilience and physical health when adjusted for all physical health measures. Higher levels of resilience were associated with decreased odds of depressive symptomology, measured with the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977).
Wexler, 2011	3 AN cohort groups: 7 AN elders, ages 60 years and older; 7 AN adults, ages 33–50 years; and 9 youth, ages 14–21 years.	Used Intergenerational Dialogue Exchange and Action (IDEA), an interview format. Focus groups (for youth and elders) and open-ended interviews were conducted.	IDEA offered opportunity for elder/adult/youth communication, and cross-age connections, supporting cultural knowledge transmission. Format allowed adults/elders to reflect on memories and choose stories, summarize key lessons, and give advice to the youth. Youth expressed sense of cultural identity as “learning about what the Elders have been through” (Wexler, 2011, p. 259).
Wexler, 2014	3 AN cohort groups: 7 AN elders, 60 years and older; 7 AN adults, 33– 50 years; and 9 youth, 14–21 years.	2 focus groups and 19 structured interviews conducted to investigate cultural strengths to identify ways to enhance resilience among Indigenous youth	Determined sources of strength for 3 generations to investigate how culture is shaped by past experiences and changed over time. Culture can support the people’s sense of identity, feeling of commitment to “their people,” and purpose in life. Youth were less clear about identity, and showed limited ability to use cultural strengths to overcome challenges.

Grandbois and Sanders’s (2009) work with eight AI elders revealed that resilience is grounded in culture, inter and intra relationships (i.e., families and communities), and the stories of survival by ancestors; the authors concluded that, to understand and study AI resilience, future work should be approached in context of an AI worldview (a shared perspective that includes beliefs, values, and assumptions that shapes the lives and very identity of AI people; Cross, 1998; Grandbois & Sanders, 2009). The scientific method alone may not capture the full meaning of resilience in Native cultures, requiring researchers to consider a more inclusive perspective of the multifaceted aspects of AI life philosophy (Grandbois & Sanders, 2009).

A second study by Grandbois and Sanders (2012) was based on the same project data, but focused on resilience and stereotyping; the authors assessed the elders’ narratives relative to overcoming stereotyping, through acculturation and traversing two worlds (AI and dominant society). Elders reported that they ignored stereotypes and hostile groups, and resisted internalizing these encounters (Grandbois & Sanders, 2012). Additional findings from the narratives indicated that resilience was reinforced by attaining education and employment (Grandbois & Sanders, 2012). The elders’ narratives expressed the importance of bridging dominant culture and traditional cultures to develop resilience and self-confidence to participate in both worlds. Elders were taught by their parents to be responsible, accountable, and strong, instilling a sense of pride that provided strength to face challenges. Based on the findings, the authors recommended that resilience strategies gleaned from the narratives should be used as a foundation to address health disparities.

The study by Browne, Mokuau, and Braun (2009) demonstrated that resilience is gained through culture and reaffirming cultural practices in daily living. The study showed that policies to return federal land and to promote cultural renaissance (i.e., NH culture, language, and religious practices) have been at the forefront in enhancing resilience from the individual to the community level for current and future NH populations.

Schure et al. (2013) measured resilience with the Connor-Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003) to determine potential associations with other physical and mental health measures. Schure et al. (2013) found associations between resilience and increased mental and physical health when unadjusted for all associations. However, the cross-sectional design of the study prevented meant that the direction of causality could not be determined, indicating a need for future research to use other robust designs to test resilience and its impact on mental and physical health outcomes.

Wexler (2011, 2014) described an intergenerational exchange study using a community-based participatory research approach with AN youth, adult, and elder participants. The themes that emerged from the stories included maintaining family relationships and feeling a commitment to “their people,” believing in themselves, relying on others, and feeling pride in culture (Wexler, 2011). Wexler (2014) used the same data to further investigate how resilience is enhanced by culture, and examined the association among resilience, well-being, and culture by identifying the ways in which culture offers protection and fortitude. The narratives revealed how the different generations accessed and used cultural understanding when facing challenges. While youth needed support to form cultural identity and an understanding of group membership, adults and elders were more likely to identify cultural-based strengths through a situated perspective, which helped them face challenges by using intergenerational strengths, being grounded in traditions and culture, and feeling part of something larger than themselves. Cultural identity is a key strategy in providing a sense of belonging and the resources needed to overcome challenges (Wexler, 2014).

Urban AI Elders’ Research Project

The elders’ narratives yielded the themes of culture, youth activities, and education to support resilience for youth (see Table 2).

Table 2. Description of American Indian Elder Resilience Themes and Patterns Relating to Youth Resilience.

Theme	Patterns	Examples of Patterns
Culture	Know tribal roots and history	Teach historical events (e.g., AI children sent to boarding school) and share family stories (e.g., grandparents as role models, reservation living) to help youth reflect on the past to build identity for the future
	Value intergenerational relationships	Build connection between youth and elders through cultural activities (e.g., farm with grandparents) and strengthen family networks (i.e.. introduce children to relatives) to help youth understand family lineage
	Engage in cultural activities	Engage youth by sharing cultural teachings, connecting them to the land (e.g., care for yard and garden) and have them take part in sweat lodge or talking circles
	Draw personal strength from cultural teachings and values	Teach youth they can use personal strength from positive thinking and spiritual faith (e.g., prayer) to get through challenges
	Build character traits from cultural teachings	Encourage positive character traits in youth to build their personal character (e.g., respect body, enjoy life even with limited income) and how they interact with others (i.e.. respect women)
Youth Activities	Engage in traditional activities	Engage youth in traditional activities (e.g., drum circles, dancing, powwow) to expose youth to activities not often experienced in urban settings
	Engage in contemporary activities	Engage youth in contemporary activities in urban settings that are low cost (e.g., free community events) and activities that are family based (i.e. traveling, camping, grandparents taking grandkids on educational trips)
Education	Support for education	Support education through community programs (e.g.,, clothing bank helping youth meet basic needs, TIC offering tutoring and helping youth apply for college)
	Take responsibility for own education	Teach youth personal responsibility for reaching educational goals by sharing personal experiences and lessons learned (e.g., high school dropouts can get GEDs)
	Value parental involvement	Parents support and influence youth to pursue and complete school by offering means and resources to increase exposure to educational opportunities (e.g., parents enroll youth in after-school programs such as YMCA)
	Enhance motivation for education	Build motivation in youth to reach educational goals by offering positive reinforcement (e.g., higher education helps youth have a job they really like)

Culture

The elders defined culture as teachings and values centered on knowing one’s tribal roots and history, understanding intergenerational relationships, and engaging in cultural activities. The use of fundamental cultural values and teachings emerged as a resilience strategy for building personal strength and character traits, such as generosity, responsibility, and a strong work ethic.

Knowing roots and history emerged as a key concept for culture. Understanding history and historical trauma, and sharing stories of the past, helps children understand their identity and honor the past. The elders shared that it was important for parents to teach children about their roots and history so they can understand who they are as AIs. One elder shared how people from his tribe had experienced historical racism and discrimination from the nearby city as an example of historical trauma. He wanted youth to know what their ancestors had faced so they could be proud of their heritage and honor the past. Another elder stressed that the wounds of historical trauma should not be forgotten because past trauma has contributed to loss of identity.

Establishing and maintaining intergenerational relationships was another key concept identified in the culture theme. Elders stated that connecting youth with elders and teaching kinship ties was needed so children know their relatives within the tribe. Nurturing intergenerational relationships was recommended to provide an opportunity for elders to teach youth about cultural beliefs and practices, language, and traditional roles. The elders also stressed that engaging in cultural activities, such as planting or making baskets, help children understand their roles in life and the connection between people and nature, the animate and inanimate.

Among the fundamental cultural teachings and values was the importance of having personal strength to overcome challenges. Elders stated strength can be accessed by praying to a higher power, identified as the Creator, a great one, and God. Strength, according to the elders, also is found in knowing that good is at the end of a hardship, that experiencing hardship is necessary to become strong, and that their ancestors overcame hardship.

The culture theme also included the importance of building positive character traits, such as sharing, being responsible, having a good work ethic, and not being jealous. Elders stressed having a voice and standing up for oneself, and respecting oneself and others.

Youth Activities

Elders talked about traditional and contemporary activities that build resilience among youth. They suggested that traditional activities be added to school curricula as a way to bridge the gap between youth and elders; in particular, they suggested incorporating elders and their teachings into the classroom. One elder suggested forming AI clubs, such as a Boys and Girls Club, where youth could be engaged in cultural activities in urban settings. These urban AI elders thought teaching youth about local food systems would create awareness of local resources, even if they had limited access to the natural environment. They suggested teaching youth to collect food such as saguaro fruit (local to the Tucson desert environment) and to grow fruit and vegetables in the city, to reinforce cultural strengths and, in turn, support resilience. Other elders suggested teaching youth about ranch life, including raising and butchering cows.

The contemporary activities mentioned by the elders included involving youth in programs, such as the youth coalition at the TIC, summer camps, and reading and writing programs. Elders advocated that youth stay physically active through a variety of sports and activities such as volleyball, basketball, biking, walking, and dancing. Elders felt youth should get involved in community service and volunteer work, such as trash pickup, to build responsibility and a sense of community connection. Other suggested contemporary activities included mental health programs to address depression and thoughts of suicide, money management, and gun safety workshops for youth.

Education

Elders stressed the importance of formal education and taking responsibility for one’s education, having parental involvement, and enhancing motivation for education.

Elders encouraged youth to pursue higher education or vocational training after college to compete successfully in the world. They shared that growing up in challenging conditions, such as poverty, taught them important values of working hard, staying in school despite the odds, getting more education beyond high school, and making sure to work toward getting a good job or career. Elders stated that students need to feel responsible getting an education and persevering despite hardship.

Elders identified parental involvement as an important component of education and youth resilience. Parental support helps youth finish school and meet educational and career goals. Elders stated that parents can show their support by visiting their children’s school and talking to teachers about their children’s academic performance or school behavior. Elders also suggested that parents teach their children to be responsible with money and set high expectations for their children to attend college.

The elders expressed that motivation could be instilled by teaching youth not to take things for granted and to know their purpose for existing so that they understand the importance of getting an education. They also shared that youth also can be motivated to use their education to work with and help AI communities. Other motivators include grandparents encouraging their grandchildren to stay in school, make the right choices, and use their education to make a good living.

The TIC was identified as a key resource to support education, particularly by offering a place for youth new to Tucson to begin to fit in and feel comfortable in a new city. While elders identified education as important, they also felt youth should return to their families’ home reservation-based communities to help their people, no matter how long or far their schooling took them away from home.

DISCUSSION

The three themes linked to resilience identified in the interviews with the TIC elders— culture, youth activities, and education—are echoed in the literature reporting resilience narratives collected from non-urban AI elders (Browne, Mokuau, & Braun, 2009; Grandbois & Sanders, 2009, 2012; Wexler, 2011, 2014). These parallel themes indicate that AI/AN/NH elders draw strength from a shared cultural identity to be proactive in engaging in traditional and contemporary activities and achieving educational goals. AI/AN/NH elders’ wisdom, drawn from their experiences, transcends the urban/reservation dichotomy and is applicable to today’s AI/AN/NH youth. Similarities between the research project results and the literature review illustrate that elders identified culture-based strategies used throughout their lifetimes to overcome hardship, and offered these strategies for youth to build their resilience.

Culture-based Strategies

TIC elders asserted that building resilience in youth is tied to knowing their cultural identity, and to understanding history and stories of the past. This finding is supported in Grandbois and Sanders’ work (2009, 2012), which reports that elders stated children should learn about and apply strengths drawn from their culture, history, heritage, and traditional lifestyle. TIC participants shared that building inter- and intrapersonal relationships among family, community, and, especially, elders, would help youth build a sense of connection and belonging. These important networks would provide needed opportunities to teach and share cultural beliefs and practices. Similarly, Grandbois and Sanders (2009) found that elders valued interpersonal relationships and connection to their family, tribal groups, and clanship, and expressed the importance of having a “community identity” rather than a sole identity as an individual. Wexler’s (2011) intergenerational study similarly revealed the importance of family relationships and having a sense of commitment to people in one’s family and community.

According to the elders’ narratives, youth resilience is influenced by gaining strength to overcome challenges, which can be done by calling on a higher power or listening to stories about survival. A similar belief was shared by elders in the Grandbois and Sanders (2009) study, who identified that shared history and survival of historical atrocities sustained the people’s resolve. This research warrants further work to understand the role of history in building resilience strategies. Correspondingly, Wexler (2014) reported that AN elders and adults gained strength from their ancestors and felt grounded through their connection to traditions and culture.

TIC elders linked resilience to positive character traits, including being responsible and being a dedicated worker to support oneself and one’s family. The Grandbois and Sanders (2012) study also found that elders thought being taught responsibility and a sense of pride by their own parents contributed to their raising their children as survivors.

Activity-based Strategies

TIC elders suggested youth participate in traditional activities to enhance their sense of cultural belonging and identity as a resilience strategy to face challenges associated with living in an urban environment (e.g., prejudice, stereotyping, depression, substance use). Grandbois and Sanders (2012) similarly described cultural strengths drawn from traditional practices such as making music, dancing, building relationships by visiting family and friends, and storytelling to teach life lessons and bring comfort.

TIC elders also acknowledged the role of contemporary activities to enhance urban youth resilience and build positive life skills to avoid negative situations. Contemporary activities such as sports and behavioral health programs (e.g., suicide and depression prevention) were suggested to support youth resilience. Connection between health and resilience is supported by the work of Schure et al. (2013) who found an association between resilience and improved mental and physical health among AI elders.

Education-based Strategies

TIC AI elders identified education as a strategy for building urban AI youth resilience. Elders stressed the importance of youth obtaining an education in order to successfully compete in the White world. The elders in the Grandbois and Sanders (2012) study similarly expressed that it was important to achieve educational goals and gainful employment, repeating the adage that knowledge fostered power.

This literature review had a few notable differences from the research project. Browne, Mokuau, and Sanders (2012) studied policy change to build resilience and identified the Native Hawaiian Health Care Improvement Act as a policy that has promoted social justice in the health care system. The TIC elders did not directly propose policy changes, but did suggest potential areas for program and policy development by proposing that elders share knowledge and teachings as part of school curricula. Elders’ knowledge for culture-based strategies also suggests potential policy implications for future public health interventions directed towards urban AI/AN youth. Funding mechanisms could support interventions that incorporate ways to enhance cultural understanding and strengths, build stronger intergenerational relationships, and increase participation in cultural activities.

Limitations of This Study

This study did not survey all social science databases, or any unpublished work. Additionally, there were limitations pertaining to the research project that collected TIC elders’ narratives. Only elders affiliated with the TIC were recruited; female participants dominated the sample. Most of the participating elders had actually grown up on rural reservations or outside of Tucson and were drawing on those early life experiences and projecting to urban AI youth.

CONCLUSION

Based on results from the literature review and research project, public health efforts designed to enhance AI youth resilience should include building intergenerational communication strategies, promoting cultural strengths among youth, and supporting contemporary youth activities and education. Intergenerational communication and connection can help youth learn and understand elders’ stories and strategies of resilience when faced with past adversities, thus reinforcing resilience through cultural identity. Promoting cultural knowledge and identity further draws on culture as a sustaining force offering inter- and intrapersonal strengths to youth as they build a foundation into adulthood. Intergenerational relationships allow youth to understand that culture is more than just engaging in cultural activities; it offers deeper meaning and values for creating life philosophy and understanding the purpose of life. Contemporary activities and education can guide youth through challenges presented by the urban setting. Support for intergenerational relationships, such as involving elders in school or afterschool programs may be an effective strategy to integrate strengths offered by both culture and education.

The project with TIC elders solicited in-depth and complex life narratives to yield culturally relevant assets applicable to public health efforts to promote resilience strategies. Understanding the similarities and differences among AIs and other Indigenous groups can inform resilience research to build collective strengths. Resilience research offers an innovative path to guide policy development to shape determinants of health for future generations.

AUTHOR INFORMATION

Ms. Kahn is a Doctoral Candidate in Maternal and Child Health at the University of Arizona Mel & Enid Zuckerman College of Public Health. She is the corresponding author and can be reached at 1295 N. Martin Ave., PO Box 245163, Tucson, AZ, 85724 or ckahn@email.arizona.edu.

Dr. Reinschmidt is an Assistant Professor of Health Promotion Sciences at the University of Arizona Mel & Enid Zuckerman College of Public Health, 1295 N. Martin Ave, Drachman Hall A210, PO Box 245209, Tucson, AZ, 85724. She can also be reached at (520) 626–8565 or kerstin@email.arizona.edu.

Dr. Teufel-Shone is a 2015 Fulbright Scholar at the University of Alberta, Canada and is Chair and Professor of Family and Child Health at the University of Arizona Mel and Enid Zuckerman College of Public Health, 1295 N. Martin Ave. PO Box 245209, Tucson, AZ, 85724. She can also be reached at (520) 626–9676 or teufel@email.arizona.edu.

Ms. Oré is a Doctoral Candidate in Public Health Policy and Management at the University of Arizona Mel & Enid Zuckerman College of Public Health, 1295 N. Martin Ave., PO Box 245163, Tucson, AZ, 85724. She can also be reached at core@email.arizona.edu.

Ms. Henson is a Research Specialist at the University of Arizona Mel & Enid Zuckerman College of Public Health, 1295 N. Martin Ave., PO Box 245163, Tucson, AZ, 85724. She can also be reached at m_henson06@yahoo.com.

Ms. Attakai the Director of Health Disparities Outreach & Prevention Education at the University of Arizona Mel & Enid Zuckerman College of Public Health, 1295 N. Martin Ave, Drachman Hall A202, PO Box 245163, Tucson, AZ, 85724. She can also be reached at (520) 626–4727 or agnesa@email.arizona.edu.